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More information on appealing a denial

On Behalf of | Feb 22, 2023 | Denied Insurance Claims

On a recent blog, we explored appealing a health insurance denial. In that post, we focused on an internal appeal where you appealed directly to the health insurance company that denied your claim. In this post, we transition to an external review.

External health insurance claim denial review

There are, essentially, two steps in the external health insurance claim denial review process. The first part is the written review request that must be filed, usually, within four months of the denial. And, the second part is the review and decision by the external reviewer. Whatever the decision, your insurance provider must accept the external reviewer’s decision.

Denials that you can get reviewed externally

If the denial required a medical judgment, an external review is allowable. If the treatment was denied because it was deemed experimental, as opposed to investigational, it too can qualify for external review. False or incomplete information insurance cancellations also qualify.

Rights during external reviews

There are federal consumer protection standards, as well as state consumer protection standards that govern the external review process. And, each insurance company must offer an external review process that follows both. However, for states that do not have an external review process, the United States’ Department of Health and Human Services oversees the external review process. The insurance company could also utilize an independent review organization as well. All of this information will be in your Explanation of Benefits, in addition to your insurance denial.

External review timeline

Reviews are done quickly, but no later than 45 days after the external review request is received. You can request an expedited review, which is generally done within 72 hours or fewer. Of course, you can always contact your Oklahoma City, Oklahoma, insurance dispute attorney as well to fight your case.